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Transcript
Common Eye Problems
In General Practice
Steven B. Siepser, MD, FACS
Attending Surgeon: Wills Eye
C. A. Gunderson, M.D.
Macro Approach ocular diagnosis
Slit lamp for ophthalmologist
 History for Family Physician
 Gross appearance and clues
 Diagnosis confirmation
 Risk Management

Anatomy Demonstration

External
Chemosis
Lacrimal system and eye musculature
American Academy of Ophthalmology
Common Eye Disorders:
Front to back anatomical Approach
Ocular Movement
 Lids
 Orbit
 Lacrimal System
 Conjunctiva
 Cornea
 Globe

Diagnostic steps to evaluate any eye patient
# 1 Visual Acuity
 Short history and observation
 Eye versions
 Pupils tested
 Conjunctival discharge?
 Inspect cornea for opacities or irregularities
 Stain cornea with fluorescein

Straight Eyes?
Strabismus
 Thyroid Disease
 Exophthalmous
 Isolated lateral rectus paralysis
 Diabetes
 Isolated 3rd
 Intracranial
 6th Nerve palsy

Cardinal Signs
Third Nerve Palsy
Third Nerve
Diabetes
 Advanced testing
 Glucose tolerance
 Hypertension
 Uncontrolled
 Neuro-consultation

Diagnostic Tools
Diagnostic steps
Anterior chamber Depth
 Side Light
 Irregularities in pupil
 Look for proptosis
 Lid position
 Eye movement

Anterior Chamber Depth Estimation
American Academy of Ophthalmology
Dilation “Lite”
Mydriacyl .5%
 Pupillary check
 Make sure they return to normal in 8 hours.

Checking Vision

Available methods:
 Snellen letters
 Finger counting
 Simple approach flinch
Proptosis
Forward displacement of the globe
 Orbital or cavernous sinus disease
 Children, orbital infection or tumor
 Increasing severity
 Conjunctival hyperemia
 Limitation of ocular movement

Proptotic eye
Larger than the normal eye
White sclera showing
Lid Disorders
Hordeolum/Chalazion
 Blepharitis

Chalazion
Starts as diffuse, tender, swelling
 localization of a nodule to the lid
 Hordeolum
 staphylococcal infection
 Glands of Zeis
 Lid margin
 Chalazion
 meibomian gland obstruction

Chalazion Animation
Hordeolum/Chalazion Treatment

Treatment
 Warm compresses
 5 minutes,4 times/day
 Zymar or Vigamox
 Zylet (steroid-antibiotic)
 Bacitracin ointment at night
 Prophylaxis
Hordeolum/Chalazion Treatment
Contd
Lesions present for more than a month
 Refer to an ophthalmologist
 Incision and drainage is often needed
 Systemic antibiotics
 Hordeolum or chalazion with extension
 Periorbital Cellulitis

Masquerading Lesions
Chalazion.
Blepharitis
Chronic lid margin inflammation
 Types: staphylococcal or seborrheic
 Symptoms
 Foreign-body sensation
 Burning, debris
 Predispose
 Chalazia, blepharoconjunctivitis
 Lash loss

Blepharitis
Crusting in the lashes
Thickened lid margin
Blepharitis Treatment
Warm compresses
 Lid scrubs
 Johnson and Johnson’s baby shampoo
 Thera-scrubs
 Bacitracin ointment
 Bedtime
 Restasis
 Doxycycline

Preseptal Cellulitis - Symptoms
Severe lid edema
 Eyelid erythema
 Normal ocular motility
 Normal pupil exam
 Fever
 Preauricular and submandibular adenopathy

Orbital Cellulitis
Posterior to the orbital septum
 Affects orbital contents
 Medical emergency
 Emergent consultations
 Infectious Disease
 Ophthalmologist
 Otolaryngologist

Orbital Cellulitis
Causes
Ethmoid Sinusitis
 Paranasal Sinusitis
 Dacryocysitis
 Untreated
 Younger patients

Orbital Cellulitis:
Lid swelling
Erythema
Nasolacrimal Duct (NLD) Obstruction:
Congenital and acquired




90% resolve without treatment
Intermittent Infections
Tears overflow
Treatment
 Lacrimal sac
 Probe and irrigation
Pattern of Redness
Ciliary flush –
iritis
acute glaucoma
American Academy of Ophthalmology
Conjunctival hyperemia:
American Academy of Ophthalmology
Corneal epithelial disruption

Observe reflection from the cornea
 Disruptions cause distortion and irregularity
 Fluorescein
 Breaks in the epithelium
 Stain bright yellow
 Cobalt blue light
• Bright Green
Symptoms can help determine the
diagnosis
Symptom
Cause
Itching , sandy feeling
Allergy
Scratchiness/ burning
Trichiasis, dry eye
Sharp ocular pain
Foreign body, Abrasion
Localized tenderness
Dacryocystitis , Chalazion
Symptoms
Symptom
Cause
Deep, intense pain
Episcleritis, Iritis, acute
glaucoma, sinusitis
Photophobia
Corneal abrasions, iritis, acute
glaucoma
Corneal edema, acute glaucoma,
contact lens over wear
Halo Vision
Common Eye Findings in
conjunctivitis

Eyemaginations
Pupillary abnormalities
Pupil smaller
 Iritis
 Inflammatory adhesions
 Pupil fixed and mid-dilated
 Acute angle closure glaucoma
 Marcus Gunn
 Optic Nerve Damage

Conjunctivitis
Inflammation
 Erythema
 Several causes:
 Bacterial
 Viral
 Allergic
 Chemical

Conjunctivitis Key

History
 Recent contact with red eye
 Spread
 Crusting or discharge?
 Any changes in vision?
 Does it itch?
Conjunctivitis - Discharge
Discharge
Purulent
Cause
Bacteria
Clear
Viral
White, stringy mucous
Allergies
Bacterial Conjunctivitis
Erythema
 Purulent discharge
 May be monocular
 Morning crusted shut

Bacterial conjunctivitis
Purulent discharge
Conjunctival hyperemia
American Academy of Ophthalmology
Bacterial Conjunctivitis
Treatment
Broad spectrum topical antibiotics
 Polytrim, Ocuflox, Ciloxan
 Warm compresses, remove crusts
 School once on antibiotics
 Refer
 4 day rule
 Any vision change

Viral Conjunctivitis
Adenovirus
 Systemic viral infections
 Painful
 Herpetic
 Discordant lack of pain

Viral Conjunctivitis (non-herpetic)
HIGHLY CONTAGIOUS
 One eye to the second eye
 Often recent contact “pink eye”
 Children must be kept out of school
 Wash your hands and everything touched

Viral conjunctivitis - symptoms
Often bilateral
 Often with diffuse, marked hyperemia
 Watery discharge
 Chemosis ( swelling of conjunctiva)
 Some itching and foreign body sensation
 Preauricular adenopathy
 URI, sore throat, fever common

Viral conjunctivitis
Diffuse redness
Watery discharge
Viral conjunctivitis - treatment
Cold compresses
 Good hygiene – wash hands, do not share
 Topical treatment for symptom relief
 Patanol, Acular
 No role for topical antibiotics
 Refer
 Decrease in Vision
 No resolution

Viral Conjunctivitis - Herpetic
Profuse watery discharge
 Eyelid ulcers and vesicles
 Permanent scarring and visual loss
 Refer
 Herpetic diagnosis made
 Decreased vision
 History of recurrence

Herpetic corneal lesion
Dendritic pattern.
American Academy of Ophthalmology

Rose Bengal Stain
Allergic Conjunctivitis
Hay fever, asthma, eczema
 Bilateral, seasonal
 Mild conjunctival hyperemia
 Chemosis prominent
 Itching and sandy feeling
 Not contagious

Conjunctivitis-Allergic
Erythema
No watery discharge
Allergic conjunctivitis - treatment
Cold compresses
 Topical antihistamines (Livostin)
 Topical non-steroidals (Acular)
 Topical mast cell stabilizers (Alomide)
 Not effective until after one week of use
 Restasis
 Pataday

Subconjunctival hemorrhage
Bleeding
 Potential space: conjunctiva and sclera
 Resolve without sequelae
 No treatment
 Trauma,coughing, sneezing, coumadin
 No need for referral

Subconjunctival hemorrhage
Dry Eyes

Associated with:
 Aging
 Females
 Rheumatoid arthritis
 Systemic medications
 Topical medications
Dry eyes - treatment
Artificial tear drops
 Systane
 Refresh
 Restasis
 Refer
 Punctal plugs
 Punctal occlusion

Cornea
Corneal Abrasions
 Corneal Ulcers
 Herpetic Keratitis
 Chemical Burns

Corneal Abrasions
Trauma
 Contact lens wear
 Symptoms:
 Pain, photophobia, redness
 Tearing, blurred vision
 Usually monocular

Corneal Abrasions - Diagnosis
Fluorescien dye
 Cobalt – blue light
 Abrasion will appear green.
 Topical anesthetic
 Alcaine
 Proparacaine

Corneal Abrasions - treatment




Heal within 24 hours
Topical antibiotic drop
 Acular (Ibuprofen for the eye)
Patient followed daily
Refer to ophthalmologist
 Bandage contact lens
 Debridement
 Failure to heal in 24 hours
Patching technique






Antibiotic drop into the eye
Proparacaine
Close both eyes
Place two eye pads over the affected eye
Tape firmly start on Cheek for tension
The patch should be removed in 24 hours
Pressure patch applied to left eye
Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
Corneal Ulcer
A localized, penetrating, infection
 Bacterial
 Fungal or protozoan (ameoba)

Corneal Ulcer: Signs/Symptoms







Pain
Photophobia, Fixed pupil
Foreign body sensation
Conjunctival hyperemia
White opacity on the cornea
Anterior chamber inflammation (iritis)
Hypopyon (pus in the anterior chamber)
Corneal Ulcer
Finger trauma
 Contact lens wear
 Tree=Fungus

Corneal Ulcer:
white lesion on the central cornea
hypopyon
conjunctival hyperemia
American Academy of Ophthalmology
Herpetic Keratitis
Herpes simplex virus
 Follow up
 Place Patient on Acyclovir
 Refer

Dendritic lesion of herpetic keratitis
Herpetic Keratitis
Complications and prognosis
Recurrent process
 Corneal scarring
 Leads to visual loss

Acid Injuries
Acid burns
 Damage limited to area of contamination
 Sulfuric and Nitric acids most common
 Industrial
 Automobile battery explosions

Alkaline Injuries
Penetrate rapidly
 Produce intense ocular reactions
 Damage widespread, progressive
 Corneal opacification
 Scarring, severe dry eye
 Glaucoma and blindness

Chemical Injury: Treatment
Proparicaine
 Complete and copious irrigation of the eye
 Eye irrigation solutions or saline IV drip
 Irrigate under the lids

Chemical Injury: Treatment
Check the pH
 Place litmus paper
 Resume irrigation until pH neutralized
 Recheck pH in 30 minutes
 pH can rise after irrigation stopped

Iritis – signs/symptoms
Ciliary flush
 Photophobia (light sensitivity)
 Miotic pupil
 Keratic precipitates

Hyphema
Blood in the anterior chamber
 Usually associated with trauma
 Requires emergent referral

Hyphema –
Layer of blood
American Academy of Ophthalmology
Laceration
Document Vision
 No direct Pressure
 Pupil points to opening
 Can be disguised with blood and mucous
 Place shield
 NPO, refer

Laceration
Thank You.
Questions?
 Considerations?
 More topics for discussion?
